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Acta Dermatovenerol Croat
2014;22(2):85-90
REVIEW
Self-inflicted Skin Lesions: A Review of the Terminology
Hans Christian Ring*, Matthias Nybro Smith*, Gregor BE Jemec
Department of Dermatology, Roskilde Hospital, Health Sciences Faculty, University of
Copenhagen, Denmark
*Both authors contributed equally to the manuscript
Corresponding author:
Hans Christian Ring, MD
Department of Dermatology
Roskilde Hospital
Health Science Faculty
Køgevej 7-13
4000 Roskilde, Denmark
[email protected]
Received: November 13, 2013
Accepted: May 30, 2014
SUMMARY The current literature on the management of self-inflicted skin lesions points
to an overall paucity of treatments with a high level of evidence (randomized controlled
trials, controlled trials, or meta-analyses). In order to improve the communication between
dermatologists and mental health professionals, the European Society for Dermatology
and Psychiatry (ESDaP) recently proposed a classification of psychodermatological terms
in order to establish a coherent use of terms across the medical fields involved.
We reviewed current and previous psychodermatological diagnoses in order to clarify
how the previous plethora of terms is covered by the new classification.
This may aid physicians and mental health professionals in understanding how the new
classification relates to the prior plethora of psychodermatological diagnoses and thereby
facilitate the future use of the new classification.
Key words: terminology, psychodermatology, self-inflicted skin lesions
Introduction
The terminology within the field of psychodermatology is currently the subject of much debate due to
an abundance of confusing and often contradictory
terms. This may impede the management of these
diseases, as the treatment is often a multidisciplinary
cooperation between dermatologists and mental
health professionals where clarity and consistency
in terminology is essential. Furthermore, the many
confusing terms referring to the same few conditions may complicate the dissemination of important knowledge. In keeping with this, a recent survey
study of dermatologists demonstrated that only a
small minority among the responders felt they had a
clear understanding of the field of psychodermatology and the conditions that fall under it (1).
Realizing the need for a coherent use of terminology across the medical disciplines involved, the European Society for Dermatology and Psychiatry (ESDaP)
recently proposed a classification of psychodermatological conditions (2).
ACTA DERMATOVENEROLOGICA CROATICA
In order to facilitate an optimized understanding
of the proposed terminology, we have reviewed the
previous and current utilization of the psychodermatological terminology.
This may aid physicians and mental health professionals in understanding how this new classification
relates to the earler plethora of psychodermatological diagnoses and may facilitate the future use of the
new classification.
The following is a brief introduction to the recently proposed classification of diagnoses by ESDaP.
Factitious disorder in dermatology (FD) has been
defined as a set of faked or self inflicted skin lesions
created without clear external incentives. Comorbidity of psychiatric origin is often present in these patients (e.g. anxiety or depression) and a majority of
the patients may at first not acknowledge their role in
the creation of the lesions due to possible dissociative
episodes. Furthermore, as in Münchausen syndrome,
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Table 1. Overview of the abundant psychodermatological terminology seen in relation to the recent recommendations from ESDaP
ESDaP recommendations
Factitious disorder in dermatology
Skin-picking syndrome
Rhinotillexomania
Dermatillomania
Acne excoriée
Trichotillomania
Trichophagia
Synonyms used
Dermatitis artefacta (7)
Factitial dermatitis (26)
Self-induced factitial dermatitis (27)
Facticial dermatitis (28)
Dermatitis factitia (28)
Artefactual skin disease (9)
Factitious illness (11)
Illness falsification (11)
Dermatological pathomimicry (12)
Cutaneous artefactual disease (8)
Dermatitis simulata (29)
Factitious skin disease (30)
Neurotic excoriation (16)
Dermatillomania (16)
Psychogenic excoriation (16)
Compulsive skin picking (2)
Pathologic skin picking (31)
Skin picking disorder (32)
Dermatitis para-artefacta (2)
Self-injurious skin picking (33)
Repetitive skin picking (33)
Emotional excoriations (34)
Nervous scratching artefact (34)
Paraartificial excoriations (34)
Epidermatillomania (34)
Acne urticata (34)
Pathological nose picking (2)
Compulsive nose picking (35)
Psychogenic excoriations (16)
Neurotic excoriations (16)
Skin picking syndrome (16)
Excoriation (17)
Neuromechanical alopecia (17)
Hair pulling disorder(32)
Pathologic hair pulling (36)
Trichorrhizophagia (37)
Trichoteiromania
Trichotemnomania
Onychophagia
Self inflicted cheilitis
Morsicatio buccarum
Pathological nail biting (36)
Cheilitis factitia (2)
Facticial cheilitis (38)
Factitious cheilitis (39)
Factitious lip crusting (40)
Malingering in dermatology
Dermatitis artefacta (13-15)
Delusional infestation
Delusional parasitosis (41)
Psychogenic parasitosis (42)
Ekboms syndrome (43)
Pseudoparasitic dysaesthesia (17)
Delusions of parasitosis (44)
Parasitic dermatophobia (45)
Parasitophobia (45)
Entomophobia (45)
Acarophobia (45)
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Notes
Several inconsistencies regarding the
definition
The recommended term encompasses
both the compulsive and the impulsive
spectrum
No synonyms identified
The term was coined to describe
patients who exclusively eat the root of
the hair.
No synonyms identified
N0 synonyms identified
No synonyms identified
The term has been misinterpreted as
dermatitis artefacta
Delusional infestation may fall outside
the scope of SISL
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Terminology of self-inflicted skin lesions
these patients are assumed to have a preference for
the patient’s role (3). However, in Münchausen syndrome patients feign an acute disease with exaggerated, overly-dramatized symptoms and give a false
medical history. Although self-inflicted skin lesions
may be a part of the syndrome, these patients present a generally more flamboyant clinical picture and
often move between hospitals (4).
“Malingering” is a broad term that refers to feigning or production of illness for fraudulent purposes.
In dermatology this often takes the form of self inflicted skin lesions inflicted while fully aware, with the
objective of achieving apparent advantages such as
financial gain or exemption from work. The common
denominator between malingering and factitious
disorders is that the infliction of skin lesions occurs
in secrecy, though the motivation for self-mutilation
differs (3).
In striking contrast to both FD and malingering,
patients with skin picking syndrome do not have any
fraudulent purposes or other definite aims, and are
fully aware of having caused the lesions themselves.
The syndrome encompasses both the impulsive and
compulsive spectrum (2). Compulsive skin damaging is a repetitive form of self mutilation where the
patients may experience a sensation of relief through
their self-inflicting behavior, and attempts to manage
or control the urge often results in increased tension
(e.g. trichotillomania or acne excoriê) (5).
Impulsive skin picking is often found among borderline patients and appears to be provoked by a
situation with intractable emotional circumstances.
The mutilation is considered to be the patient’s way
of coping with stressful situations, as it may provide a
short-lived relief from the emotional disarray (6).
Method
We reviewed psychodermatological articles and
investigated the use of the terminology and diagnostic classification of self-inflicted skin lesions (SISL).
PubMed, Embase, and PsychINFO databases were
systematically searched. The research applied different combinations of Medical Subject Headings
(MeSH): “Self injury, behaviour AND (factitious disorders OR malingering OR Münchausen OR skin picking syndrome)”. We limited the literature search to articles written in English, Danish, Norwegian, Swedish,
or French. We placed no restrictions in terms of year
of publication.
Since several psychodermatological terms do not
exist as a MeSH terms, we also performed a free-text
search on various terms e.g. “dermatitis artefacta”,
“psychogenic excoriation” and “artefactual skin dis-
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2014;22(2):85-90
ease” in PubMed, and then retrieved further references from the related articles.
Discussion
As attested to by the literature, it is evident that
dermatitis artefacta is by far the most frequently applied synonym for factitious disorder in dermatology
(7). However, the term “dermatitis artefacta” seems
somewhat misleading, as it suggests an underlying
inflammation which is not necessarily present in selfinflicted lesions. This has also been noted by several
authors, and Lyell (8) and Roger et al. (9) addressed
these “term-issues” and instead suggested “cutaneous artefactual disease” and “artefactual skin disease”,
respectively (Table 1). Furthermore, there also appear to be remarkable inconsistencies regarding the
definition. It seems to derive from a disagreement on
whether the self-infliction is carried out in full awareness or not. This is noteworthy as there is a widespread
consensus on the fact that these patients may dissociate from the self-inflicting episode. Disagreements
on the extent to which these patients benefit from
their self inflicting behavior have also arisen. Authors
have stated that these patients may harm themselves
in order to escape responsibility or to collect disability insurance (10). This is a striking misinterpretation
of the term, since patients suffering from a factitious
disorder do not have any immediate tangible benefits. The term “factitious” is also used in describing
other self-inflicted disorders, e.g. factitious cheilitis,
and its justification in this context is questionable. In
this context, the term “factitious” appears somewhat
confusing as the lesions are neither denied nor hidden by the patient.
Illness falsification and factitious illness have been
used synonymously, with factitious disorder referring to intentional fabrication of diseases (e.g. fever
or purpura) in all the medical disciplines (11). Along
with malingering, dermatological pathomimicry has
also been used in the context of factitious disorders
in dermatology. The condition refers to the induction
of lesions mimicking features of well-recognized dermatological disorders. The initial description of the
term from Millard stated, however, that one should
not confuse the term with “dermatitis artefacta” (12).
Unlike factitious disorder in dermatology, malingering appears to have been used in dermatology without various synonyms although it may be
confused with the much less used “pathomimicry”.
Unfortunately, within the spectrum of SISL the term
“malingering” has not seen as widespread use as one
could have hoped for. There are several examples in
the literature of articles describing self-inflicted skin
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Terminology of self-inflicted skin lesions
lesions in soldiers seeking exemption from military
duty without mention of malingering and with using
the term dermatitis artefacta (factitious disorder in
dermatology) applied erroneously instead (13-15).
Skin picking syndrome encompasses both the
compulsive and the impulsive spectrum. The term
skin picking itself has been used synonymously with
disorders such as neurotic excoriations, dermatillomania, or psychogenic excoriations (16). It has been
noted that the synonyms may be considered pejorative and stigmatizing, and thus some authors discourage the use of these terms (17).
The nomenclature in compulsive skin picking
disorders and related skin damaging syndromes appears to have a vast array of synonyms, although this
is not applicable to every compulsive disorder (e.g.
acne excoriê). Even though ESDaP recommends the
use of the term “trichotillomania”, that term has been
used inconsistently, and authors have advocated its
replacement with “neuromechanical alopecia” as they
find “mania” stigmatizing (17). Nonetheless, “trichotillomania” appears to be the most widely applied term
in dermatology, and thus it is also the preferred term
according the ESDaP authors.
One may speculate whether all psychodermatologic diseases have their place within the spectrum
of self-inflicted skin lesions (SISL), this being particularly debatable for delusional infestation (DI) due to
its psychiatric nature. Patients with delusional infestation are convinced that they are infected with various
organisms (e.g. parasites, bacteria, or viruses) often
leading to self inflicted excoriations of the skin (18).
Although the term may fall outside the strict sense
of SISL, the patients may still constitute a perplexing issue viewed from a dermatological perspective.
The term “delusional infestation” has been frequently
used, with “delusional parasitosis” (DP) as the most
common synonym. However, it has been noted that
“delusional parasitosis” does not cover patients convinced that they are infected with species other than
parasites, therefore the term appears inadequate as it
does not cover the whole spectrum of possible “intrusive” pathogens (19). In contrast, “delusional infestation” is an all-encompassing term as it covers all possible species. The common denominator between
DI and DP is the use of the term “delusional” which
appears preferable to e.g. “parastiophobia” as the patients have a fixed false belief (delusion) and not a
phobia. Furthermore, authors have stressed that that
the term “delusional” may potentially be interpreted
as degrading and have attempted to rename the disorder to “pseudoparasitic dysaesthesia” (17).
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2014;22(2):85-90
Münchausen syndrome was first introduced by
Asher in 1951 (20) and its definition has scarcely
changed since then (21). The syndrome is akin to factitious disorder but is distinguished by its extreme
presentation and more refractory illness (22). Three
characteristic features define Münchausen syndrome:
1) factitious symptoms, 2) hospital or doctor “shopping”, and 3) pseudologia phantastica (pathological
lying characterized by wildly exaggerated stories)
(2,22). Some argue that these criteria are inherently
difficult to operationalize, and should therefore be
abandoned in favor of the broader term factitious disorder (23). Indeed, the syndrome was removed from
the DSM classification by the fourth version, though
it still sees widespread use in published articles and
letters (24).
Lastly, it should be noted that the term “Münchausen syndrome” is preferable to “Münchausen’s syndrome”, the preference for the non-possessive form
being due to the fact that Munchausen has no proprietary claim on the entity (25).
Conclusion
The current literature available on the management of self-inflicted skin lesions points to an overall
paucity of treatments supported by a high level of
evidence (randomized controlled trials, controlled
trials, or meta-analyses). Our overview of the abundant psycho-dermatological terminology seen in
relation to the recent recommendations from ESDaP
may contribute to the necessary framework for future
therapeutic trials leading to the development of evidence based guidelines. This may optimize the multidisciplinary cooperation between the medical fields
involved, which is considered crucial in the management of psychocutaneous disorders.
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